HomeMy WebLinkAboutSeptic - Septic Pumping Slip - 78 TANGLEWOOD LANE 11/18/2025 ti Commonwealth of Massachusetts Town of North Andover
� y City/Town of
m System Pumping RecordNOV 1, 202 Farm 4
DEP has provided this form for use by local Boards of Health Other 411-na�'rrrby beased, but the .�
inforrrlation must be substantially the sarne as that provided here. Before using this'f'or'r 'chisdlkwith your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351
HOUSE: ront back side re fight
A. Facility Information BUILDING: front back side rear le right
important:When DECK: under
filling out forms 1. System Location:
on the computer, j
use only the tab _—__ _ _ u✓�"! '. _ 1� -'
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key to move your Address
cursor-do not MA
use the return
key, State
Cit mown __Zip_ e_ ..._......_.__..._..._ _.
Y Cod
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ame
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Address(if different from location)
MA
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---- ..___—_ _.._.._._ _.. _-.-- --
ity(7�own
T (e e Numt�er
B. Pumping Record
1. Date of Pumping __._ __.___I_� 2 Quantity Pumped',
Dale; y p Gallons
3. Component: [.[ Cesspool(s) ( Septic Tank ❑ Tight Tank
g ❑ Grease Trap
Other (describe): - _..____ _..--_--._-_-__--
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes rya
5. Observed condition of component purnpp]e/d:
3. System humped By:
L7ave -__neY _....__.. _ .-..._ Mass 1 AA95P. .___. ass 1 AD31 Z
8 Vehicle License, tVurnt7er
Bateson Enterprises, Inc.
Cornpany
7. 6calior wh e con tents were disposed,
S
Slgnalura of Hauler Date __----
.__.__.__ _---------._._
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Signature of Receiving facility(or attach facility recF;ip!) C1ate
t5form4.doc- '1 1/12 System Purnping Record -Pagre 1 of 1